How Can We Do Less, When More Is SOP?

How a hernia illustrates systematic problems

Today, during afternoon practice, one of the residents came to my office to present a patient, an initial visit being seen for establishment of care after a recent emergency room visit.

The patient was a healthy young man in his 40s, without any significant prior medical history, who experienced a popping sensation in his abdomen several days earlier after lifting a heavy object at work.

When he developed some abdominal discomfort later that same day, he brought himself into our emergency room, where he was evaluated by the emergency room staff.

Internal Medicine and Hernia Repair -- a Mismatch?

The resident had reviewed the emergency room notes and data, and in the end the patient was discharged with a plan to follow up in our internal medicine practice for his ventral hernia.

So he was sent here, instead of to the general surgery clinic, the place where they fix hernias?

I looked quickly at the impressive amount of data, documentation, and testing that had been done on him, sent from the ED via uplink to our EHR.

I laughed a little. The resident smiled, but then I noticed that his smile seems somewhat nervous.

Wait, really? They sent a troponin on him?

Actually, two troponins, separated by several hours.

Nothing in the history we saw recorded in the ED or that the resident had gotten from the patient suggested anything like an acute coronary syndrome in this healthy young man without any cardiac risk factors. It sounded he lifted something, and developed a hernia. It sounded like this is what they thought in the emergency room.

But somehow we ended up with a massive collection of labs, an ultrasound to confirm the hernia they felt on exam, and then a CT of his abdomen and pelvis to reconfirm those same findings.

And to top it off, instead of simply sending him on to surgery clinic, they referred him to the internal medicine practice, where our main intervention was likely simply going to be to refer him to a general surgeon.

One of the latest things sweeping through the healthcare community is the "less is more" movement, an effort to get us away from overtesting, overdiagnosis, overtreating, to really move towards saner and more evidence-based care decisions, but how can we do this in the current environment?

We all understand that in emergency rooms one is dealing with imperfect data, and one of the major fears of every emergency room doc is sending home that acute MI.

We see the same thing on the inpatient services, where patients get daily labs, phlebotomized to the point of anemia, x-rayed to the point where they glow-in-the-dark, tested until no mysteries remain, much of it is of little benefit.

And we are not immune to this in the outpatient world. How many CBCs and TSHs have been sent in the name of fatigue, when all the patient really needed to be told was to stop eating so much junk and start exercising. How many scans have been done because patients hinted that someone they knew had the same symptoms and their doctor ignored them and they were dead a month later? How many antibiotics have been given to colds since it takes 30 seconds to prescribe and 30 minutes not to?

Standard default lab panels are everywhere, CYA medicine has become the norm, and it's easier to order tests than not.

Is PCMH a Better Way?

Unless we can change the defensive practice of medicine and the litigious environment we live and we practice in, it's going to be really hard to truly achieve "less is more."

Might the patient-centered medical home offer a better system to allow us to transition, safely and effectively, into an environment where we can truly achieve "less is more"?

Think of it: access 24/7 to a healthcare team, professionals who can help you decide what course of action is right, whether it be an acute care visit at an outpatient practice, or communication with an urgent care center or emergency room to safely get you the care you need when you need it.

All of the members of the healthcare team could be involved, to bring the patient in, to assess them accurately, to direct them appropriately to some specialist care, to avoid unnecessary over-testing.

If anything, this starts with establishing a relationship with the primary care practitioner and the patient-centered care team around them, so that everyone has a PCP somewhere in the world.

Wouldn't that be great?

Providers in emergency rooms would have access to a patient's complete prior medical records, and open channels of communication to talk with the patient's primary care provider. Expedited appointments with subspecialists could be easily arranged, and members of the team could ensure safe, timely, and adequate (but not excessive) follow=up.

This patient ultimately did have some incidental findings uncovered, which is one of the arguments made against the idea of "less is more," but more than likely if this patient was under long-term care of a primary care practitioner these things would have been detected earlier.

Perhaps even his obesity, which likely led to the weakening of his abdominal wall which led to the hernia, might have been addressed and thus avoided this whole incident. As it was, the resident referred him on to surgery clinic, and, hopefully, he will have an uneventful repair of his hernia in the near future.

By getting him into the system now, perhaps we can end up preventing unnecessary tests on him in the future, so hopefully no one will need to CT scan him again.

None of us want to become gatekeepers; the world of pre-authorization and insurance companies deciding what tests we can and cannot do, Big Brother looking over our shoulders as we try to practice the art of medicine, is not the answer.

But the creation of a more sensible system, where we don't feel we need to test everybody for everything all the time out of fear and desperation, and where we are not doing things that we know don't make sense and should be avoided at all costs, is sure to be a better place in which to deliver high quality healthcare to all of our patients.

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